Adrenaline for prevention of morbidity and mortality in preterm infants with cardiovascular compromise

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Abstract
Inotropes are widely used in preterm infants to treat cardiovascular compromise, which may result from early adaptive problems of the transitional circulation, perinatal asphyxia or sepsis. Sustained hypotension and poor organ blood flow are associated with brain injury including peri/intraventricular haemorrhage and subsequent poor neurodevelopmental outcomes. Adrenaline (epinephrine) infusions are used in preterm infants with clinical cardiovascular compromise. To determine the effectiveness and safety of adrenaline compared to no treatment or other inotropes in reducing mortality and morbidity in preterm infants with cardiovascular compromise. Randomised controlled trials were identified by searching MEDLINE (1966‐August 2003), The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2003) and EMBASE (1980 ‐ 2003), supplemented with searches of reference lists of published trials and abstracts of conference proceedings. Randomised controlled trials of preterm newborn infants that compared adrenaline to no treatment or other inotropic agents (including dopamine, dobutamine, noradrenaline or isoprenaline). Data were extracted and analysed independently by two reviewers. Treatment effects on the following outcomes were to be determined: mortality in the newborn period, long term neurodevelopmental outcomes, radiological evidence of brain injury, short term haemodynamic changes, adverse drug effects and short term neonatal outcomes. Study authors were contacted for additional information. Studies were analysed for methodological quality using the criteria of the Cochrane Neonatal Review Group. One ongoing study (Pellicer 2003) was identified. One study comparing adrenaline with dopamine infusion was included but was published in abstract form only (Phillipos 1996). It enrolled hypotensive, predominately preterm infants in the first 24 hours. Only infants >1750g are included in this review (report for infants <=1750g appears incomplete). The study was reported as being randomised and double blinded, but methods were not reported. Both adrenaline and dopamine significantly increased heart rate and mean BP, with no statistically significant effect on left or right ventricular outputs. No other clinical outcomes were reported. No studies were identified that compared adrenaline to other inotropes, placebo or no treatment. There are insufficient data on the use of adrenaline infusions in preterm infants with cardiovascular compromise to make recommendations for practice. There is a need for larger trials to determine whether adrenaline is effective in reducing morbidity and mortality in preterm infants with cardiovascular compromise. Adrenaline(腎上腺素)預防心血管窘迫的早產兒的發病率和死亡率 強心藥物被廣泛應用於早產兒治療心血管窘迫，心血管窘迫可能導致過度期循環早期的適應問題，新生兒周產期窒息或敗血症。持續性低血壓和差的器官血流量都與腦損傷，包括周圍/腦室內出血及後續神經發育不良的結果有關. Adrenaline(腎上腺素)輸注可被用於早產兒臨床心血管窘迫。 在早產兒心血管窘迫, 要確定Adrenaline相比於不治療或其他強心藥物, 其降低死亡率和發病率的有效性和安全性。 通過搜索MEDLINE(1966年−2003年8月)，Cochrane中心註冊的對照試驗(CENTRAL, The Cochrane Librar，2003年,第3期)和EMBASE(1980  2003)，輔以補充搜索會議紀錄的摘要和已發表試驗的參考名單, 來確認隨機對照試驗。 在早產新生兒中，比較腎上腺素治療與不治療或其他強心藥物(dopamine, dobutamine, noradrenaline 或 isoprenaline)的隨機對照試驗。 兩個評審獨立進行數據提取和分析。處理下列成果來作出決定：新生兒期死亡率，長期神經發展結果，腦損傷的放射影像證據，短期內血流動力學變化，藥物不良影響和短期新生兒結果。也聯繫了研究的作者來了解更多信息。使用 Cochrane新生兒審查小組的標準來進行研究的方法學品質分析。 一個正在進行的研究(Pellicer 2003年)被確定。另外有一項研究比較adrenaline與dopamine輸注被納入本文章內，但發現其只有摘要出版(Phillipos 1996年)。它收入低血壓，第一個 24小時出生為主的早產兒。只有>1750克嬰兒包括在此review報告(< = 1750克嬰兒的報告並不完整)。該研究報告中提到隨機雙盲，但沒有報告方法。adrenaline與dopamine兩者都顯著增加心率和平均血壓，無顯著影響左或右心室輸出。沒有其他臨床結果的報告。沒有找到其他研究比較腎上腺素與其他強心藥物，安慰劑或不治療。 沒有足夠的數據建議使用adrenaline輸注來治療早產兒的心血管窘迫。需要更大的試驗以確定是否在心血管窘迫早產兒使用adrenaline可降低發病率和死亡率。 本摘要由臺中榮民總醫院薛榮華翻譯。 此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。 沒有足夠的試驗證據證明較差心跳和循環的早產兒使用adrenaline(腎上腺素)的功效。持續血流不暢可導致早產兒併發症，包括發展受損。 強心藥物，尤其dopamine 和 dobutamine，常用來增加血液循環不良早產嬰兒的心率和血壓. Adrenaline(腎上腺素)是另一個可以被使用的強心藥物。Review發現，沒有足夠的試驗證據證明adrenaline對早產嬰兒的血液循環不良有效果，還需要更多的研究證明。